As reflected in the-topic of this proposal, the applicant has two main career goals: (I) to evaluate the quality of surgical and non-surgical treatment for low back pain; and (2). to reduce variation in treatment practices and improve the outcomes of treatment for these conditions. This five-year project combines the use of outcomes research and continuous quality improvement techniques to close the gap between knowledge gained through outcomes research and clinical practices to improve outcomes for patients with low back pain. Despite its frequency and related costs, little is known about the quality of care for spinal disorders. The data and infrastructure provided by the recently initiated Spine Patient Outcomes Research Trials (SPORT) presents a unique opportunity to study, compare, and improve outcomes for patients undergoing treatment for three surgically treatable spine conditions: herniated disc, spinal stenosis, and degenerative spondylolisthesis. SPORT is a set of clinical trials to compare the effectiveness of surgical and non-surgical approaches to the treatment of these conditions that is being conducted at II U.S. medical centers and expects to enroll approximately 3000 patients. The overall goals of this proposal are to evaluate and improve the quality of care for low back pain through a comparative study of the structure, process, and outcomes of care at medical centers participating in SPORT. Specifically, this proposal has three research objectives: 1. To characterize clinical practices. We plan a detailed study of variability in structures and processes of care for patients with low back pain at the sites participating in SPORT. 2. To assess outcomes of care. After developing and validating methods for risk-adjustment, we will evaluate and compare quality of care for low back pain across the II sites participating in SPORT. Outcomes, to be assessed in both surgically and non-surgically treated patients, will include functional health status, clinical outcomes, patient satisfaction, and cost. 3. To link clinical practices and outcomes. Using statistical models to account for random variation in the setting of hierarchical data structures, we will examine associations between clinical structure, process, and outcomes to identify high-leverage areas for improvement. Improving clinical care can not occur in the vacuum of a research laboratory. At each step of this project, we will feedback data to clinicians at the participating medical centers and work with them to develop a focused quality improvement agenda that is designed to improve patient outcomes by reducing variability in clinical practices.